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Ren J, Bowyer A, Tian DH, Royse C, El-Ansary D, Royse A. Multiple arterial vs. single arterial coronary artery bypass grafting: sex-related differences in outcomes. Eur Heart J 2024:ehae294. [PMID: 38820177 DOI: 10.1093/eurheartj/ehae294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 02/24/2024] [Accepted: 04/30/2024] [Indexed: 06/02/2024] Open
Abstract
BACKGROUND AND AIMS Uncertainty exists over whether multiple arterial grafting has a sex-related association with survival after coronary artery bypass grafting. This study aims to compare the long-term survival of using multiple arterial grafting vs. single arterial grafting in women and men undergoing coronary artery bypass grafting. METHODS The retrospective study used the Australian and New Zealand Society of Cardiothoracic Surgical Database with linkage to the National Death Index. Patients from 2001 to 2020 were identified. Sex-stratified, inverse probability weighted Cox proportional hazard model was used to facilitate survival comparisons. The primary outcome was all-cause mortality. RESULTS A total number of 54 275 adult patients receiving at least two grafts in primary isolated bypass operations were analysed. The entire study cohort consisted of 10 693 (19.7%) female patients and 29 711 (54.7%) multiple arterial grafting procedures. At a median (interquartile range) postoperative follow-up of 4.9 (2.3-8.4) years, mortality was significantly lower in male patients undergoing multiarterial than single arterial procedures (adjusted hazard ratio 0.82; 95% confidence interval 0.77-0.87; P < .001). The survival benefit was also significant for females (adjusted hazard ratio 0.83; 95% confidence interval 0.76-0.91; P < .001) at a median (interquartile range) follow-up of 5.2 (2.4-8.7) years. The interaction model from Cox regression suggested insignificant subgroup effect from sex (P = .08) on the observed survival advantage. The survival benefits associated with multiple arterial grafting were consistent across all sex-stratified subgroups except for female patients with left main coronary disease. CONCLUSIONS Compared to single arterial grafting, multiple arterial revascularization is associated with improved long-term survival for women as well as men.
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Affiliation(s)
- Justin Ren
- Department of Surgery, University of Melbourne, 300 Grattan St, Parkville, Melbourne 3052, Australia
- Department of Cardiothoracic Surgery, Royal Melbourne Hospital, 300 Grattan St, Parkville, Melbourne 3052, Australia
| | - Andrea Bowyer
- Department of Surgery, University of Melbourne, 300 Grattan St, Parkville, Melbourne 3052, Australia
- Department of Anesthesia, Royal Melbourne Hospital, Melbourne, Australia
- Outcomes Research Consortium, Cleveland Clinic, Cleveland, OH, USA
| | - David H Tian
- Department of Surgery, University of Melbourne, 300 Grattan St, Parkville, Melbourne 3052, Australia
- Department of Anaesthesia and Perioperative Medicine, Westmead Hospital, Sydney, Australia
| | - Colin Royse
- Department of Surgery, University of Melbourne, 300 Grattan St, Parkville, Melbourne 3052, Australia
- Department of Anesthesia, Royal Melbourne Hospital, Melbourne, Australia
- Outcomes Research Consortium, Cleveland Clinic, Cleveland, OH, USA
| | - Doa El-Ansary
- Department of Surgery, University of Melbourne, 300 Grattan St, Parkville, Melbourne 3052, Australia
- School of Biomedical and Health Sciences, Royal Melbourne Institute of Technology, Melbourne, Australia
| | - Alistair Royse
- Department of Surgery, University of Melbourne, 300 Grattan St, Parkville, Melbourne 3052, Australia
- Department of Cardiothoracic Surgery, Royal Melbourne Hospital, 300 Grattan St, Parkville, Melbourne 3052, Australia
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Stefanyk K, Ghunaim A, Vervoort D. Commentary: Off-pump and on point: Sex-stratifying multiple arterial grafting. J Thorac Cardiovasc Surg 2024; 167:1808-1809. [PMID: 36944562 DOI: 10.1016/j.jtcvs.2023.02.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 02/21/2023] [Indexed: 03/05/2023]
Affiliation(s)
- Kelsey Stefanyk
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Abdullah Ghunaim
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Dominique Vervoort
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.
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Aboul-Hassan SS, Hirnle G, Perek B, Jemielity M, Hirnle T, Brykczynski M, Deja M, Rogowski J, Cisowski M, Krejca M, Anisimowicz L, Widenka K, Gerber W, Pacholewicz J, Bugajski P, Stepinski P, Maruszewski BJ, Cichon R, Hrapkowicz T. Single versus multiple arterial coronary artery bypass grafting in men and women: results from Polish National Registry of Cardiac Surgery Procedures. Int J Surg 2024; 110:2234-2242. [PMID: 38324262 PMCID: PMC11020110 DOI: 10.1097/js9.0000000000001133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 01/24/2024] [Indexed: 02/08/2024]
Abstract
BACKGROUND The objective of this multicenter study aimed to investigate the impact of sex on long-term survival among patients with multivessel coronary artery disease undergoing coronary artery bypass grafting (CABG) using multiple arterial grafting (MAG) or a single artery with saphenous vein grafts. MATERIALS AND METHODS Data were obtained from the Polish National Registry of Cardiac Surgery Procedures database. This study included 81 136 patients who underwent CABG for multivessel disease between January 2012 and December 2020 (22.9 were women and 77.1% were men). MAG was performed in 8.3 and 11.7% of female and male patients, respectively. A 1:1 propensity score (PS)-matching was performed. Long-term mortality was compared between matched groups of men and women. Subgroup analyses of patients aged <70 and ≥70 years, with an ejection fraction (EF) >40% and ≤40%, and with and without diabetes, obesity, peripheral artery disease (PAD), or chronic lung disease (CLD) were performed separately in women and men. RESULTS MAG was associated with lower long-term mortality than saphenous vein grafts in 1528 PS-matched female pairs [hazard ratio (HR): 0.74; 95% CI: 0.59-0.92; P =0.007) and 7283 PS-matched male pairs (HR: 0.80; 95% CI: 0.72-0.88; P <0.001). Subgroup analyses confirmed the results among female patients aged <70 years, with diabetes and EF >40%, and without PAD or CLD, and of male patients aged <70 and ≥70 years; with EF >40%; with or without diabetes, obesity, or PAD; and without CLD. CONCLUSIONS In patients undergoing CABG, MAG was associated with significantly improved survival in both sexes. The long-term benefits of MAG observed across subgroups of men and women support the consideration of a multiarterial revascularization strategy for a broader spectrum of patients.
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Affiliation(s)
- Sleiman Sebastian Aboul-Hassan
- Department of Cardiac Surgery, Zbigniew Religa Heart Center ‘Medinet’, Nowa Sol
- Department of Cardiac Surgery and Interventional Cardiology, Faculty of Medicine and Medical Sciences, University of Zielona Gora, Zielona Gora
| | - Grzegorz Hirnle
- Department of Cardiac Surgery, Transplantology, Vascular and Endovascular Surgery, Medical University of Silesia in Katowice, Silesian Centre for Heart Diseases, Zabrze
| | - Bartlomiej Perek
- Department of Cardiac Surgery and Transplantology, Chair of Cardio-Thoracic Surgery, Poznan University of Medical Sciences, Poznan
| | - Marek Jemielity
- Department of Cardiac Surgery and Transplantology, Chair of Cardio-Thoracic Surgery, Poznan University of Medical Sciences, Poznan
| | - Tomasz Hirnle
- Department of Cardiac Surgery, Medical University of Bialystok, Bialystok
| | - Miroslaw Brykczynski
- Department of Cardiac Surgery, Zbigniew Religa Heart Center ‘Medinet’, Nowa Sol
- Department of Cardiac Surgery and Interventional Cardiology, Faculty of Medicine and Medical Sciences, University of Zielona Gora, Zielona Gora
| | - Marek Deja
- Department of Cardiac Surgery, Medical University of Silesia, Katowice
| | - Jan Rogowski
- Department of Cardiac and Vascular Surgery, Medical University of Gdansk, Gdansk
| | - Marek Cisowski
- Department of Cardiac Surgery, University Hospital, Institute of Medical Sciences, University of Opole, Opole
| | - Michal Krejca
- Department of Cardiac Surgery, Chair of Cardiology and Cardiac Surgery, Medical University of Lodz, Lodz
| | - Lech Anisimowicz
- Department of Cardiac Surgery, Collegium Medium, Nicolaus Copernicus University, Bydgoszcz
| | | | - Witold Gerber
- Department of Cardiac Surgery, American Heart of Poland, Bielsko-Biała
| | - Jerzy Pacholewicz
- Department of Cardiac Surgery, Pomeranian Medical University, Szczecin
| | - Pawel Bugajski
- Department of Cardiac Surgery, J. Strus Hospital
- Faculty of Health Sciences, University of Medical Sciences, Poznan
| | - Piotr Stepinski
- Department of Cardiac Surgery, Chair of Cardiology and Cardiac Surgery, Medical University of Lodz, Lodz
| | - Bohdan J. Maruszewski
- Department of Pediatric Cardiothoracic Surgery, The Children’s Memorial Health Institute, Warsaw, Poland
| | - Romuald Cichon
- Department of Cardiac Surgery, Zbigniew Religa Heart Center ‘Medinet’, Nowa Sol
- Department of Cardiac Surgery and Interventional Cardiology, Faculty of Medicine and Medical Sciences, University of Zielona Gora, Zielona Gora
| | - Tomasz Hrapkowicz
- Department of Cardiac Surgery, Transplantology, Vascular and Endovascular Surgery, Medical University of Silesia in Katowice, Silesian Centre for Heart Diseases, Zabrze
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Ren J, Tian DH, Gaudino M, Fremes S, Reid CM, Vallely M, Smith JA, Srivastav N, Royse C, Royse A. Survival Benefit of Multiple Arterial Revascularization With and Without Supplementary Saphenous Vein Graft. J Am Heart Assoc 2023; 12:e031986. [PMID: 37947115 PMCID: PMC10727302 DOI: 10.1161/jaha.123.031986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Accepted: 10/11/2023] [Indexed: 11/12/2023]
Abstract
Background It is unknown if the presence of saphenous vein grafting (SVG) adversely affects late survival following coronary surgery with multiple arterial grafting (MAG) versus single arterial grafting. Methods and Results A retrospective, observational, multicenter cohort study from 2001 to 2020 was conducted using the Australian and New Zealand Society of Cardiac and Thoracic Surgeons Database linked to the National Death Index. Patients undergoing primary isolated coronary artery bypass grafting with ≥2 grafts were included, and exclusions were patients aged <18 years, reoperations, concomitant or previous cardiac surgery, and the absence of arterial grafting. Demographics, comorbidities, medication, and operative configurations were propensity score matched between cohorts. The primary outcome was all-cause late death. Of 59 689 eligible patients, 35 113 were MAG (58.8%), and 24 576 were single arterial grafting (41.2%). Of the MAG cohort, 17 055 (48.6%) patients did not receive supplementary SVG (total arterial revascularization). Matching separately generated 22 764 patient pairs for MAG versus single arterial grafting, and 11 137 patient pairs for MAG with total arterial revascularization versus MAG with ≥1 supplementary vein grafts. At a median follow-up duration of 5.0 years postoperatively, the mortality rate was significantly lower for MAG than single arterial grafting (hazard ratio [HR], 0.79 [95% CI, 0.76-0.83]; P<0.001). The stratified MAG analysis found that MAG with total arterial revascularization had a lower risk of late death (HR, 0.85 [95% CI, 0.80-0.91]; P<0.001) compared with MAG with ≥1 supplementary vein grafts. Sensitivity analyses produced consistent outcomes as the primary analysis. Following adjustment for the presence of SVG in the Cox model, the survival advantage of incremental number of arteries was lost. Conclusions Multiple arterial grafting has significantly improved long-term survival compared with single arterial grafting. A further incremental survival benefit exists when no SVG is used.
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Affiliation(s)
- Justin Ren
- SurgeryUniversity of MelbourneMelbourneAustralia
| | - David H. Tian
- SurgeryUniversity of MelbourneMelbourneAustralia
- Anesthesia, Westmead HospitalSydneyAustralia
| | - Mario Gaudino
- Cardiothoracic Surgery, Weill Cornell MedicineNew YorkNY
| | | | | | - Michael Vallely
- Cardiothoracic SurgeryVictorian Heart Hospital and Monash UniversityMelbourneAustralia
| | - Julian A. Smith
- Cardiothoracic SurgeryVictorian Heart Hospital and Monash UniversityMelbourneAustralia
| | | | - Colin Royse
- SurgeryUniversity of MelbourneMelbourneAustralia
- Outcomes Research ConsortiumCleveland ClinicClevelandOH
- AnesthesiaRoyal Melbourne HospitalMelbourneAustralia
| | - Alistair Royse
- SurgeryUniversity of MelbourneMelbourneAustralia
- Cardiothoracic Surgery, Royal Melbourne HospitalMelbourneAustralia
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Ren J, Royse C, Srivastav N, Lu O, Royse A. Long-Term Survival of Multiple Versus Single Arterial Coronary Bypass Grafting in Elderly Patients. J Clin Med 2023; 12:jcm12072594. [PMID: 37048677 PMCID: PMC10094898 DOI: 10.3390/jcm12072594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 03/24/2023] [Accepted: 03/27/2023] [Indexed: 03/31/2023] Open
Abstract
Multiple arterial grafting (MAG) utilizes more than one arterial graft with any additional grafts being saphenous vein grafts (SVG). It remains an infrequently used coronary surgical revascularization technique, especially in elderly patients. Our study aims to evaluate the age-related association with the relative outcomes of multiple versus single arterial grafting (SAG). The Australian and New Zealand national registry was used to identify adult patients undergoing primary isolated CABG with at least two grafts. Exclusion criteria included reoperations, concomitant or previous cardiac surgery, and the absence of arterial grafting. Propensity score matching was used to match patient groups. The primary outcome was all-cause late mortality and the secondary outcomes were 30-day mortality and 30-day hospital readmission. We selected 69,624 eligible patients with a mean (standard deviation) age of 65.0 (10.2) years old. Matching between MAG and SAG generated 16,882 pairs of patients < 70 years old and 10,921 pairs of patients ≥ 70 years old. At a median [interquartile range] follow-up duration of 5.9 [3.2–9.6] years, MAG was associated with significantly reduced mortality compared to SAG (hazard ratio [HR], 0.73; 95% confidence interval [CI], 0.68–0.78; p < 0.001) in the younger subgroup as well as the elderly subgroup (HR, 0.84; 95% CI, 0.79–0.88; p < 0.001). In conclusion, MAG offers a survival benefit over SAG, in both younger and elderly patients.
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Ren J, Royse C, Royse A. Late Clinical Outcomes of Total Arterial Revascularization or Multiple Arterial Grafting Compared to Conventional Single Arterial with Saphenous Vein Grafting for Coronary Surgery. J Clin Med 2023; 12:2516. [PMID: 37048600 PMCID: PMC10094905 DOI: 10.3390/jcm12072516] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 03/17/2023] [Accepted: 03/24/2023] [Indexed: 03/29/2023] Open
Abstract
Coronary surgery provides better long-term outcomes than percutaneous coronary intervention. Conventional practice is to use a single arterial conduit supplemented by saphenous vein grafts. The use of multiple arterial revascularization (MAG), or exclusive arterial revascularization (TAR), however, is reported as having improved late survival. Survival is a surrogate for graft failure that may lead to premature death, and improved survival reflects fewer graft failures in the non-conventional strategy groups. The reasons for not using MAG or TAR may be due to perceived technical difficulties, a lack of definitive large-scale randomized evidence, a lack of confidence in arterial conduits, or resources or time constraints. Most people consider radial artery (RA) grafting to be new, with use representing approximately 2-5% worldwide, despite select centers reporting routine use in most patients for decades with improved results. In conclusion, the current body of evidence supports more extensive use of total and multiple arterial revascularization procedures in the absence of contraindications.
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Affiliation(s)
- Justin Ren
- Department of Surgery, University of Melbourne, Melbourne, VIC 3050, Australia
| | - Colin Royse
- Department of Surgery, University of Melbourne, Melbourne, VIC 3050, Australia
- Department of Cardiothoracic Surgery, Royal Melbourne Hospital, Melbourne, VIC 3050, Australia
- Outcomes Research Consortium, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Alistair Royse
- Department of Surgery, University of Melbourne, Melbourne, VIC 3050, Australia
- Department of Cardiothoracic Surgery, Royal Melbourne Hospital, Melbourne, VIC 3050, Australia
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Vervoort D, Elbatarny M, Rocha R, Fremes SE. Reconstruction Technique Options for Achieving Total Arterial Revascularization and Multiple Arterial Grafting. J Clin Med 2023; 12:jcm12062275. [PMID: 36983276 PMCID: PMC10056232 DOI: 10.3390/jcm12062275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 03/11/2023] [Accepted: 03/14/2023] [Indexed: 03/17/2023] Open
Abstract
Ischemic heart disease is the leading cause of morbidity and mortality worldwide and may require coronary revascularization when more severe or symptomatic. Coronary artery bypass grafting (CABG) is the most common cardiac surgical procedure and can be performed with different bypass conduits and anastomotic techniques. Saphenous vein grafts (SVGs) are the most frequently used conduits for CABG, in addition to the left internal thoracic artery. Outcomes with a single internal thoracic artery and SVGs are favorable, and the long-term patency of SVGs may be improved through novel harvesting techniques, preservation methods, and optimal medical therapy. However, increasing evidence points towards the superiority of arterial grafts, especially in the form of multiple arterial grafting (MAG). Nevertheless, the uptake of MAG remains limited and variable, both as a result of technical complexity and a scarcity of conclusive randomized controlled trial evidence. Here, we present an overview of CABG techniques, harvesting methods, and anastomosis types to achieve total arterial revascularization and adopt MAG. We further narratively summarize the available evidence for MAG versus single arterial grafting to date and highlight remaining gaps and questions that require further study to elucidate the role of MAG in CABG.
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Affiliation(s)
- Dominique Vervoort
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON M5S 1A1, Canada
- Division of Cardiac Surgery, University of Toronto, Toronto, ON M5S 1A1, Canada
| | - Malak Elbatarny
- Division of Cardiac Surgery, University of Toronto, Toronto, ON M5S 1A1, Canada
| | - Rodolfo Rocha
- Division of Cardiac Surgery, University of Toronto, Toronto, ON M5S 1A1, Canada
| | - Stephen E. Fremes
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON M5S 1A1, Canada
- Division of Cardiac Surgery, University of Toronto, Toronto, ON M5S 1A1, Canada
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada
- Correspondence: ; Tel.: +1-416-480-6073
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Robinson NB, Lia H, Rahouma M, Audisio K, Soletti G, Demetres M, Leonard JR, Fremes SE, Girardi LN, Gaudino M. Coronary artery bypass with single versus multiple arterial grafts in women: A meta-analysis. J Thorac Cardiovasc Surg 2023; 165:1093-1098. [PMID: 34482958 PMCID: PMC8828799 DOI: 10.1016/j.jtcvs.2021.07.047] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 07/16/2021] [Accepted: 07/27/2021] [Indexed: 12/25/2022]
Abstract
OBJECTIVE The study objective was to investigate the impact of multiple arterial grafting on long-term all-cause mortality in women undergoing isolated coronary artery bypass grafting. METHODS A comprehensive search was performed to identify observational studies reporting outcomes after coronary artery bypass grafting reported by sex and stratified into multiple arterial grafting versus single arterial grafting strategies. Articles were considered for inclusion if they were written in English and were propensity-matched observational studies. Included studies were then pooled in a meta-analysis performed using the generic inverse variance method. The primary outcome was long-term all-cause mortality. Secondary outcomes were operative mortality and spontaneous myocardial infarction. Meta-regression was used to explore the effects of preoperative and intraoperative variables on the primary outcome. RESULTS A total of 6 studies with 32,793 women (25,714 single arterial grafting and 7079 multiple arterial grafting) were included. Women who received multiple arterial grafting had lower long-term mortality (incidence rate ratio, 0.86; 95% confidence interval, 0.76-0.96; P = .007) and spontaneous myocardial infarction (incidence rate ratio, 0.80; 95% confidence interval, 0.68-0.93; P = .003) compared with women who received single arterial grafting, but the difference in mortality disappeared when including only the 3 largest studies. There was no difference between groups in operative mortality (odds ratio, 0.99; 95% confidence interval, 0.84-1.17; P = .91). Meta-regression did not identify any associations with the incidence rate ratio for long-term mortality. CONCLUSIONS The use of multiple arterial grafting in women undergoing coronary artery bypass grafting is associated with lower long-term mortality, although the difference is mostly driven by small series. Further studies, including randomized trials, are needed to evaluate the efficacy of multiple arterial grafting in women undergoing coronary artery bypass grafting.
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Affiliation(s)
- N Bryce Robinson
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Hillary Lia
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Mohamed Rahouma
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Katia Audisio
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Giovanni Soletti
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Michelle Demetres
- Samuel J. Wood Library and C.V. Starr Biomedical Information Centre, Weill Cornell, Medicine, New York, NY
| | - Jeremy R Leonard
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Stephen E Fremes
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY.
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Velez AK, Lawton JS. Commentary: Isn't evidence a prerequisite for evidence-based medicine? J Thorac Cardiovasc Surg 2023; 165:1099-1101. [PMID: 34489103 DOI: 10.1016/j.jtcvs.2021.08.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 08/12/2021] [Accepted: 08/13/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Ana Karen Velez
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Md
| | - Jennifer S Lawton
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Md.
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Hachiro K, Suzuki T, Takashima N, Kamiya K. Off-Pump Bilateral Skeletonized Internal Thoracic Artery Grafting in Octogenarians. Circ J 2023; 87:312-319. [PMID: 36476828 DOI: 10.1253/circj.cj-22-0443] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND We compared postoperative outcomes in octogenarians who underwent off-pump isolated coronary artery bypass grafting for multivessel disease using either skeletonized bilateral or single internal thoracic artery (ITA).Methods and Results: Among 1,532 patients who underwent isolated coronary artery bypass grafting between 2002 and 2021, 173 octogenarians were analyzed retrospectively. After inverse probability of treatment weighting, we found no statistically significant difference regarding patients' preoperative characteristics. No patient experienced deep sternal wound infection. More patients in the single than bilateral ITA group died within 30 days after surgery (5.0% vs. 0%, respectively; P=0.003). The mean follow-up duration was 4.2 years. At 5 years, the freedom from overall death following bilateral versus single ITA grafting was 78.2% and 53.7%, respectively (log-rank test, P=0.003), and freedom from major adverse cardiac and cerebrovascular events (MACCE) was 67.9% and 44.8% respectively (log-rank test, P=0.002). In multivariable Cox models, bilateral ITA grafting was significantly associated with a lower risk of overall death (hazard ratio [HR] 0.555; 95% confidence interval [CI] 0.342-0.903; P=0.018) and MACCE (HR 0.586; 95% CI 0.376-0.913; P=0.018). CONCLUSIONS Compared with single ITA grafting, off-pump skeletonized bilateral ITA grafting is associated with lower rates of overall death and MACCE in octogenarians undergoing CABG and does not increase the risk of deep sternal wound infection.
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Affiliation(s)
- Kohei Hachiro
- Division of Cardiovascular Surgery, Department of Surgery, Shiga University of Medical Science
| | - Tomoaki Suzuki
- Division of Cardiovascular Surgery, Department of Surgery, Shiga University of Medical Science
| | - Noriyuki Takashima
- Division of Cardiovascular Surgery, Department of Surgery, Shiga University of Medical Science
| | - Kenichi Kamiya
- Division of Cardiovascular Surgery, Department of Surgery, Shiga University of Medical Science
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Magouliotis DE, Fergadi MP, Zotos PA, Rad AA, Xanthopoulos A, Bareka M, Spiliopoulos K, Athanasiou T. Differences in long-term survival outcomes after coronary artery bypass grafting using single vs multiple arterial grafts: a meta-analysis with reconstructed time-to-event data and subgroup analyses. Gen Thorac Cardiovasc Surg 2023; 71:77-89. [PMID: 36394709 PMCID: PMC9886578 DOI: 10.1007/s11748-022-01891-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 11/09/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVE We reviewed the available literature on patients with coronary artery disease undergoing isolated coronary artery bypass grafting (CABG) with either single (SAG) or multiple arterial grafting (MAG). METHODS Original research studies that evaluated the long-term survival of MAG versus SAG were identified, from 1995 to 2022. The median overall survival (OS) and event-free OS were the primary endpoints. Comparison of median OS between the right internal mammary artery (RIMA) and radial artery (RA) as a second arterial conduit was the secondary endpoint. Subgroup analyses were performed regarding patients older than 70 years, with diabetes mellitus, and females. A sensitivity analysis was performed with the leave-one-out method. RESULTS Forty-four studies were included in the qualitative and thirty-nine in the quantitative synthesis. After pooling data from 180 to 459 patients, the MAG group demonstrated a higher OS (HR, 0.589; 95% CI, 0.58-0.60; p < 0.0001) and event-free OS compared with the SAG group (HR, 0.828; 95% CI, 0.80-0.86; p < 0.0001). In addition, RITA was associated with superior OS compared with RA as a second arterial conduit (HR, 0.936; 95% CI, 0.89-0.98; p = 0.009). MAG was also superior to SAG in patients over 70 years, females, and patients with diabetes mellitus. Sensitivity analysis demonstrated a small-size study effect on the female subgroup analysis. CONCLUSION The present meta-analysis indicates that MAG is associated with enhanced survival outcomes compared to SAG for patients undergoing isolated CABG.
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Affiliation(s)
| | - Maria P. Fergadi
- Department of Radiology, University of Thessaly, Larissa, Greece
| | - Prokopis-Andreas Zotos
- Department of Cardiothoracic Surgery, University of Thessaly, Biopolis, 41110 Larissa, Greece
| | | | | | - Metaxia Bareka
- Department of Anesthesiology, University of Thessaly, Larissa, Greece
| | - Kyriakos Spiliopoulos
- Department of Cardiothoracic Surgery, University of Thessaly, Biopolis, 41110 Larissa, Greece
| | - Thanos Athanasiou
- Department of Surgery and Cancer, Imperial College London, London, UK
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Gaudino M, Di Franco A, Cao D, Giustino G, Bairey Merz CN, Fremes SE, Kirtane AJ, Kunadian V, Lawton JS, Masterson Creber RM, Sandner S, Vogel B, Zwischenberger BA, Dangas GD, Mehran R. Sex-Related Outcomes of Medical, Percutaneous, and Surgical Interventions for Coronary Artery Disease: JACC Focus Seminar 3/7. J Am Coll Cardiol 2022; 79:1407-1425. [PMID: 35393023 DOI: 10.1016/j.jacc.2021.07.066] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 07/12/2021] [Indexed: 12/15/2022]
Abstract
Biological and sociocultural differences between men and women are complex and likely account for most of the variations in the epidemiology and treatment outcomes of coronary artery disease (CAD) between the 2 sexes. Worse outcomes in women have been described following both conservative and invasive treatments of CAD. For example, increased levels of residual platelet reactivity during treatment with antiplatelet drugs, higher rates of adverse cardiovascular outcomes following percutaneous coronary revascularization, and higher operative and long-term mortality after coronary bypass surgery have been reported in women compared with in men. Despite the growing recognition of sex-specific determinants of outcomes, representation of women in clinical studies remains low and sex-specific management strategies are generally not provided in guidelines. This review summarizes the current evidence on sex-related differences in patients with CAD, focusing on the differential outcomes following medical therapy, percutaneous coronary interventions, and coronary artery bypass surgery.
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Affiliation(s)
- Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA.
| | - Antonino Di Franco
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Davide Cao
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Gennaro Giustino
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - C Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, California, USA
| | - Stephen E Fremes
- Division of Cardiac Surgery, Schulich Heart Centre, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Ajay J Kirtane
- Department of Cardiology, New York-Presbyterian Hospital/Columbia University Irving Medical Center and the Cardiovascular Research Foundation, New York, New York, USA
| | - Vijay Kunadian
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University and Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Jennifer S Lawton
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Sigrid Sandner
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Birgit Vogel
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Brittany A Zwischenberger
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - George D Dangas
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Toumpoulis IK, Pappa CK, Kanistras DA, Anagnostopoulos CE, Toumpoulis SK. Superiority of Bilateral Internal Thoracic Artery Grafting in Long-term Survival after Coronary Artery Bypass Through the Lenses of a Bedside Risk Score. Hellenic J Cardiol 2021; 64:15-23. [PMID: 34740799 DOI: 10.1016/j.hjc.2021.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Revised: 07/30/2021] [Accepted: 10/27/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Risk algorithms for the prediction of long-term survival after coronary artery bypass grafting (CABG) do not include the use of bilateral internal thoracic artery (BITA) grafting among the independent predictors. METHODS There were analyzed 5,666 consecutive patients who underwent isolated (n=4,715 - BITA=2,792) and combined (n=951 - BITA=246) CABG. The mean follow-up was 10.3 years (interquartile range 9.9 years). All the predictors of an existing bedside risk score (BRS) were available for analysis (age, body mass index, ejection fraction, unstable hemodynamic state, left main disease, cerebrovascular disease, peripheral arterial disease, congestive heart failure, malignant ventricular arrhythmia, chronic obstructive pulmonary disease, diabetes and previous heart surgery). Furthermore, a modified BRS was constructed taking into account the use of BITA grafting and combined CABG. RESULTS The good discriminatory ability and satisfactory calibration of the BRS was confirmed in the isolated CABG subgroup. The modified BRS showed improved discriminatory ability and similar calibration. It showed a time-varying coefficient, and accordingly, we calculated adjusted survival predictions up to 20 years after isolated and combined CABG with or without BITA grafting. Patients with BITA grafting in the low-risk quartile showed 68.4% and 65.5% predicted survival rates at 20 years in the isolated and combined CABG subgroups respectively versus 56.4% and 52.8% among patients without BITA grafting. CONCLUSIONS The modified BRS is a useful simplified algorithm for clinicians in choosing treatment intervention for severe isolated or combined coronary artery disease. We clearly demonstrated the superiority of BITA grafting in long-term survival throughout the entire range of the modified BRS.
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Affiliation(s)
- Ioannis K Toumpoulis
- National and Kapodistrian University of Athens, Department of Cardiac Surgery, Athens, Greece.
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